SERENITY NURSE AIDE ACADEMY 6636 E WT HARRIS BLVD SUITE E & G CHARLOTTE, NC 28215 PHONE : 704-567-9199 FAX : 704-567-4600 www.serenitynurseaide.com APPLICATION
NAME :
ADDRESS :
CITY :
DOB :
STATE :
SS# :
Home Phone :
Alternate No :
Cell :
Emergency# :
Email :
Are you over 18 years old
Yes No
Have you ever been convicted by any government agency of child, patient resident or elderly abuse?
Yes No if yes, please explain:
Are you being sponsored by a Medicail certified facility? Yes No
If yes, you are not responsible for any costs associated with traning including the cost of textbooks and/or supplies SPONSOR'S INFORMATION
I certify that the information provided in this applicatioun is true and complete to the best of my knowledge i agree that if i misrepresent my self or omit any relevant information or provide false answer, serenity nurse aids academy will disqualify me or discharge me from the program without refund.
(** If you have been convicted of a felony you can not enroll in Serenity Nurse Academy***)